Dr. Lois Ramondetta and her daughter Jessica Bauer pose at the University of Texas M.D. Anderson Cancer Center, where Ramondetta is a gynecologic oncologist who treats cervical cancer.

Dr. Lois Ramondetta and her daughter Jessica Bauer pose at the University of Texas M.D. Anderson Cancer Center, where Ramondetta is a gynecologic oncologist who treats cervical cancer.

Photo: Michael Paulsen, Staff

Vaccine to guard against cervical cancer is a 'no-brainer'

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Can a vaccine rise above politics and complacency and stamp out a number of deadly cancers?

The vaccine that blocks a sexually transmitted infection that causes cervical, oral and other cancers was hailed as a home run when it was approved seven years ago, but, given usage rates, doctors still aren't sure if it'll ever live up to the promise and render any of the diseases a shadow of their current lethality.

Instead, doctors are huddling to determine how to improve inoculation rates that hover at 33 percent, a figure attributed to controversy that beset the vaccine from the beginning. The controversy included concerns that the vaccine would encourage premarital sex and Gov. Rick Perry's 2007 attempt to require it of Texas school girls.

"It's just wrong that politics should play a role in this," says Dr. Lois Ramondetta, a University of Texas M.D. Anderson Cancer Center gynecologic oncologist who treats cervical cancer, the cancer for which the vaccine initially was approved. "This is the only cancer for which we know an infection is the cause and have a vaccine that prevents it. Getting vaccinated should be a no-brainer."

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By the numbers

80: percent of the population exposed to HPV at some point in their lifetime.

$1.7 billion: cost to U.S. patients and insurance companies to treat HPV, acquired in one calendar year, over the infection's course.

$390: cost (though usually covered by insurance) of three doses of the vaccine that prevents HPV.

34: percent of 13- to 17-year-old girls nationally who received three doses of the HPV vaccine in 2011

31.5: percent of 13- to 17-year-old girls in Texas who received three doses of the HPV vaccine in 2011

Sources: Centers for Disease Control; Baylor College of Medicine

The virus also is associated with a number of other cancers that researchers have begun finding are spiking - oral cancers that involve the back of the throat, tonsils and base of the tongue, and cancers of the vagina, vulva, penis and anus. Dr. Otis Brawley, chief medical officer of the American Cancer Society, recently referred to the increase as "one of the epidemics of the 21st century."

The infection is the human papilloma virus, or HPV, the most common sexually transmitted infection in the United States. At least 80 percent of sexually active people, at some point in their lives, acquire the virus, which usually causes no symptoms and is cleared by the immune system.

Still, worldwide, HPV causes roughly a half million new cases of cancer annually, mostly women in developing countries. Thanks to screenings that catch HPV at pre-cancerous levels, cervical cancer is on the decline in the United States, now annually afflicting about 13,000 women and killing 4,000.

Two vaccines - Gardasil and Cervarix - have been shown to protect against the strains of the virus that cause cervical cancer. Because neither provides any therapeutic benefit once an infection takes hold, the Centers for Disease Control recommends a series of three shots to girls at 11 to 12 years of age.

But it was that recommendation that roiled the waters. A Yale study found parental concern the vaccine could make adolescents less wary of casual sex was the biggest single factor in the decision not to vaccinate.

When Perry issued his order - overturned by the Texas Legislature later that session - making the vaccine mandatory for public school girls, the outcry included not just members of the religious right, but the leadership of the Texas Medical Association, who argued that it should stay voluntary until safety and liability issues were vetted.

"Education needs to come first," said Dr. Joseph Bocchini at the time, then the chairman of the American Academy of Pediatrics chairman of infectious diseases. "Much of the public doesn't know about HPV and its link to cervical cancer and other diseases. You can't put a mandate ahead of that."

Today, only Virginia and Washington, D.C., require the HPV vaccine of school girls. More than half of states at one point considered such legislation.

In recent years, the data about the vaccine has been positive.

In a 2012 study in the Archives of Pediatric and Adolescent Medicine, for instance, researchers evaluated the medical records of nearly 200,000 female patients between the ages of 9 and 26 and found no major adverse effects, just vaccination-day fainting and short-term skin infections.

Another 2012 study, in the journal Pediatrics, found no evidence girls vaccinated at age 12 went on to engage in more sexual activity than girls who were not vaccinated. Researchers followed nearly 1,400 girls for five years, based on markers of sexual activity, collected by a managed-care organization, such as pregnancies, counseling on contraceptives and testing for or diagnoses of sexually transmitted diseases.

Some doctors worry that without a school-age requirement, the three-dose vaccination rate won't improve much more, even though the numbers have increased from 17 percent of 13- to 17-year-old girls in 2008 to 34 percent in 2011. Compared to Australia's 80 percent to 90 percent vaccination rate, the skeptics call the U.S. experiment a failure.

But Dr. Amy Middleman, a Baylor College of Medicine pediatrician, takes heart in the increasing numbers and in recent data that shows 49 percent of Texas girls in 2011 got one shot of the vaccine. "Given all the controversy the vaccine got caught up in, I'd say that's pretty remarkable," she says. "It's important girls complete the series, but there is evidence that even one shot provides some protection."

Middleman acknowledges that the vaccine can prompt uncomfortable conversations, but adds that one reason more girls don't get vaccinated is that providers misinterpret parent attitudes. She cited a survey in Pediatrics that found parents on average rated the importance of the HPV vaccine for their child as a 7.7 on a 1-10 scale; on average, providers reported their perception of the importance parents placed for the child as a 5.6.

But the best news about the vaccine is probably a 2012 study that found that even with the limited vaccine use by girls so far, a positive spillover effect may already be developing. The study, screening for the presence of HPV in sexually active teens in 2006 and 2010, found that the rate of infection dropped dramatically among those who got the vaccine, but also appreciably among those not vaccinated.

Study authors suggested possible quick onset of the phenomenon known as herd immunity, in which the fewer the number of people carrying an infectious agent, the lower the chances of picking it up.

In that vein, one thing that should help even more: The CDC is now also recommending the vaccine for boys.